Client Intake For Menands & Watervliet - Colonie Senior Service Center

Today's Date(Required)

Date of Birth (must be 60 or older)(Required)

If Medicade, what is your Medicade #:(Required)

Client Phone #:

Cell Phone #:(Required)

Email:(Required)

Phone:(Required)

Relationship to client:(Required)

Phone:(Required)

Relationship to client:(Required)

What makes you disabled or frail?(Required)

How do you currently get around?(Required)

Can you or someone else drive you to some of your appointments? (Explain why and when you will need to use transportation)(Required)

Closest bus line & bus stop:

If you do live near a bus stop, is there any reasons why you don't ride the bus?(Required)